Mastering medical language is a must when it comes to medical coding and billing. As physicians use precise medical terminology to communicate their observations and prescriptions, medical coders and billing staff should be knowledgeable about these terms to be able to report diagnoses and procedures performed to third-party payers for accurate reimbursement. Coding spine surgeries is a challenging process, but professional coders in medical billing and coding companies can assign the appropriate codes to describe services delivered as they have a proper understanding of the spinal anatomy and terminology.
To assign the correct codes for spinal procedures, expert coders will examine the documentation to ensure that it supports the following items:
- Location: cervical, thoracic, lumbar or sacral (the 33 vertebrae are classified as 7 cervical: C1-C7; 12 thoracic: T1-T12; 5 lumbar: L1-L5; 5 Sacral, and 4 Coccygeal vertebrae
- Approach: anterior, posterior or lateral extracavity, or percutaneous
- Pathology: what was done and medical indication (decompression, disc-ectomy, corpectomy, arthrodesis)
- Bone grafting: allograft or autograft
- Instrumentation: rods, screws or cages
- Implants used
Here are some important considerations when reporting spinal procedures:
- Code assignment requires knowledge of spine anatomy: Correct CPT and ICD coding would depend on identifying which portion of the spine the physician is working to determine the approach used and level assignment for a particular procedure, according to a Beckers ASC Review report.
For example, take spinal fusion (arthrodesis). The location reflects the level of the vertebrae (cervical, thoracic, lumbar and/or sacral) and the number of vertebral joints fused. While ICD-10 codes can reflect the complexity of the procedures performed, correct ICD coding depends on knowing:
- The information required to accurately assign the characters of a spinal fusion procedure code.
- The procedures that are considered integral to the fusion and assigned separate codes and those are not integral to the fusion and not assigned additional codes.
- The number of fusion codes to assign (this depends on how many levels were fused).
A recent AAPC blog explains how to code the spinal fusion procedure. As fusion is the merging of adjacent parts, the standalone CPT code for the fusion (synonymous with “arthrodesis,” or the joining of two or more vertebrae) should be assigned. For a single fusion segment that involves adjacent vertebral segments L4 and L5, the appropriate CPT code is:
22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed
If multiple vertebral joints are fused, a separate procedure is coded for each vertebral joint that used a different device and/or qualifier. For e.g.:
- Fusion of lumbar vertebral joint, posterior approach, anterior column
- Fusion of lumbar vertebral joint, posterior approach, posterior column
Therefore, to assign the appropriate CPT and ICD-10 codes, the medical coding service provider should obtain proper and accurate information from the surgeon.
Point to note: Code 22551 should be used for the 1st level of fusion and discectomy performed and add-on code 22552 for subsequent levels. The following codes are valid when only individual procedures are performed and not combined:
22554 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2) with the separate anterior cervical discectomy/decompression code
63075 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace).
- Use standalone codes to describe decompression surgery/discectomy: Spinal decompression surgery can be performed anywhere along the spine from the neck. It involves the removal of the spinal disc, bone, or tissue causing pressure and pain. This may be the only procedure performed. Examples:Laminectomy to decompress spinal canal and/or nerve roots: CPT codes 63001-63017, 63045-+63048
Discectomy to decompress spinal canal and/or nerve roots: 63020-+63035, 63040-+63044, 63055-+63057
Corpectomy: 63081-+63091 (To use these codes, the documentation also should reflect removal of at least 50 percent of the cervical vertebral body, or 33 percent of the thoracic and lumbar vertebral bodies)Fracture repair: 22325-+22328The coder should examine the operative report to:
- Identify the presenting diagnosis
- Identify which decompression/discectomy activity was performed
- Identify whether the approach was posterior or anterior
- Assign the appropriate standalone code and any associated add-on codes
Point to note: The presenting diagnosis will determine the code when both lumbar discectomy and decompression are performed on the patient. Beckers ASC Review recommends coding a discectomy if the presenting diagnosis is disc herniation, and a decompression if the presenting diagnosis is spinal stenosis.
- Code for all levels of spinal decompression: The Beckers ASC Review report recommends careful review of the operative report to understand how many nerve roots or levels were decompressed in order to code for all appropriate levels.
- Include the appropriate add-on bone graft code with fusion: The work of placing the bone graft is included in the arthrodesis/fusion codes and a bone graft code should be included when a fusion is performed. The coder has to examine the operative report to determine:
- whether the bone graft was an allograft or an autograft, and
- whether it was a morselized (bits or pieces) or structural (wedge or chunk) bone
Bone graft codes commonly-used add-on in spine surgery include:
- Allograft (donor bone): +20930 (morselized), 20931 (structural)
- Autograft (patient’s bone): +20936, +20937 (morselized), +20938 (structural)
- Determine if hardware or instrumentation was used: The operative note should mention whether instrumentation was used in the fusion or not; if yes, where the instrument was used, and whether it was non-segmental, segmental, or intervertebral. Knowledge about the following is necessary to code instrumentation code correctly:
- If the spacer is made from titanium, PEEK or bone
- If the surgeon used a standalone cage (includes built-in hardware to anchor the device)
- Whether the implant has a separate plate and screws (these require additional CPT codes)
- Whether it is a first-time implant, removal or revision surgery.
The relevant CPT codes in this context are:
Non-segmental instrumentation (+22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure))
Segmental instrumentation (+22842-+22844) as “fixation at each end of the construct and at least one additional interposed bony attachment,” meaning at least three points of attachment on the spine
Anterior instrumentation codes (+22845-+22847) are based on the number of vertebral segments the hardware (typically, a plate) spans
Intervertebral instrumentation (+22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)) is any synthetic device, not considered a bone graft. +22851 is reported per interspace, or per vertebral defect, not by the number of devices placed in the interspace
Point to note: AAPC cautions that as instrumentation codes are add-on codes, they should not be reported with modifier 62.
For proper CPT code assignment for spinal procedures, the operative note has to support the CPT code selection as well as postoperative diagnosis. The operative note should also support medical necessity for a given procedure or service. Partnering with a medical coding company with a team of experienced AAPC-certified coders who stay updated on the latest billing and coding guidelines, as well as changes in payers’ rules can drive accurate and timely submission of claims and optimal reimbursement.